Suicide Checklist Spots People at Highest Risk

TUESDAY Nov. 8, 2011 -- The latest rating scale to determine a person's risk of committing suicide might be better than other such scales at spotting people in most urgent need of help, researchers report.

The Columbia-Suicide Severity Rating Scale (C-SSRS) was developed eight years ago and is already used by clinicians, emergency responders and others. The new study, appearing online Nov. 8 in the American Journal of Psychiatry, backs its use with new evidence.

Researchers who created the scale weighed its scientific validity against the Columbia Suicide History Form, on which the newer scale builds, and the Beck Scale for Suicide Ideation, which is considered the gold standard of assessment tools, said study author Kelly Posner, director of the Center for Suicide Risk Assessment at Columbia University.

A big difference, Posner said, is that the C-SSRS measures a wider range of potentially suicidal behaviors.

"In the past, people would [only] have asked about suicide attempts," Posner said, adding that "the scale identified a range of behaviors -- preparatory behaviors -- writing a will, buying a gun. Now we're getting at these things. [A person] with just one behavior is eight to 10 times more likely to end their life."

"Suicidal ideation" means talking or thinking about killing yourself. The scale has five degrees of ideation, ranging from "wish to be dead" to "active suicidal ideation with specific plan and intent."

"The Beck scale only looks at ideation and the Columbia History only looks at behavior," while the newer scale rates both, Posner explained. "It more clearly delineates the types of thoughts we need to get at."

Posner said that assessing suicide risk should be part of any routine medical visit.

"I believe it should be, with 50 percent of people [who commit suicide] seeing their primary care physician within the month before they die," she said. "It's a public health crisis, but a preventable public health crisis. We need to do better at screening and identifying."

The test is easy to incorporate into busy medical practices, Posner said. "Not only does it take just one or two minutes to administer, the screening version can be a few questions. It reduces false positives and it's less burdensome than not doing anything at all, when you're asking the correct questions."

Health Canada, the New York City fire department and public school system, the Baltimore police department, the U.S. National Guard and the Israeli Defense Forces have sought training in using the C-SSRS or are already using it, Posner noted.

"I get calls from judges hearing cases. They're using it to reduce unnecessary hospitalizations and interventions -- the same way schools are using it to redirect limited resources where they need to go," she said.

To evaluate the C-SSRS, the survey was given during three studies. One involved 124 adolescents who had attempted suicide and another involved 237 adults who went to a hospital emergency department for psychiatric reasons. The third was a trial testing the effectiveness of a medication for 312 depressed adolescents. The U.S. National Institutes of Health and the American Foundation for Suicide Prevention funded the research.

Lanny Berman, executive director of the American Association of Suicidology, said: "The study is a valuable addition to our understanding of suicide ideation and behavior. Its findings add weight to our hope that we can adequately measure, psychometrically, behaviors that are predictive of untoward outcomes we seek to prevent.

"This scale helps in accomplishing that with those who inform us of their having suicide ideation," Berman added. "That said, a significant proportion of those who die by suicide deny or do not inform us that they are thinking of suicide before they engage in lethal self-destructive behavior, hence we need better tools to assess risk for suicide without relying on communicated ideation as a starting point for that assessment."

Said Posner: "Some people aren't going to tell you, no matter what you ask." But, "a majority of people when asked will be forthcoming and will tell -- the point is we're better identifying those who will and are at greatest risk."

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